“We were woefully unprepared to accept that sometimes, there are no cures”

You were surrounded by family when we met you for the first time. They spoke of your immense inner strength and conviction, and of your stubbornness to live a life guided only by your own principles. Now your diminutive frame and unkempt hair bore witness to your decline in health. You winced and writhed, searching for comfort, too short of breath to speak. Your eyes gazed into ours, and an unmistakable vulnerability flashed in them. But it is still your heart we remember you for.

As we moved our stethoscopes across your chest, something caught our ears—an extra “whoosh.” Your heart valves were leaking. We listened further, and heard crackles sputtering through your lungs; they were drowning.

Your daughter asked us what we heard. Her sunken eyes reflected long, sleepless nights keeping vigil by your bed, holding her breath every time you held yours. We stood by your bedside and answered questions, losing track of time. The signs and symptoms were classic for congestive heart failure. We feared that your body, at 90 years old, would not recover from this episode. Everyone had questions—your worried daughter, your crying son, your scared granddaughter. You must have lived a good life.

We followed your care closely over the next few days. Every day, you struggled. We gave you water pills through your veins, but your kidneys became injured. We slowed down our treatment, and your heart began failing again. We heard your moans of anguish as we passed your room during our shifts on call.

You were the patient we worried about most during our 26-hour overnight call shifts. While we worked out differential diagnoses and management plans for other patients, our thoughts constantly returned to your bedside. Perhaps what was most challenging was not the fact that you were so unwell, but the sense that we were somehow complicit in your suffering.

As residents in internal medicine and neurology, we had already completed hundreds of assessments. We had been taught which questions to ask and how to conduct thorough physical exams. We had learned how to develop all-encompassing differential diagnoses and well-rounded diagnostic and management plans. We had been trained to keep digging until we found the right diagnosis and the right cure. It is no wonder, then, that we were woefully unprepared to accept that sometimes there are no cures and that sometimes the answer is to stop chasing remedies and to let go.

Every day, we promised your family that we would do everything in our power to help you. We walked a tightrope trying to find the right balance. We took more fluid away from your lungs, only to dehydrate you. We gave you fluids through your veins, only to flood your heart and lungs again. We consoled ourselves with the reminder that we were doing our best to help you, but failed to acknowledge that perhaps we were doing harm.

Because every time we drew blood to check your kidneys, we caused you pain. Every time we took your vitals, we interrupted your sleep. Every time we sedated you, we left you unable to see your family. It took us a few weeks—a few too many—to sit down with your loved ones to talk about whether we were fighting the wrong battle, about whether making you comfortable at the end of your life was more important than keeping you with us in suffering, and about whether, in trying to hang onto you, we had lost you already.

We prioritized comfort in your last days. We stopped the painful pokes for your blood. We stopped squeezing your arm to find your blood pressure. We stopped trying to find the right balance of fluids, swinging too far to the extreme every time. We stepped away, and more family stepped in. Your last days were spent surrounded by family from around the world. They spoke of a remarkable woman who raised not only her nine children, but also her nieces and nephews, her younger siblings, her grandchildren and her great-grandchildren. They recalled how you scoffed at people using calculators because of your prowess in mental math. They spoke of a gentle soul who had also been a fighter all her life and who finally seemed to be at peace.

We all came by, at various hours of the day, to see whether you were comfortable and to speak with your loved ones. We learned to reconcile our helplessness and take comfort in knowing that we were doing everything in our power to keep you comfortable in your most fragile moments (and in some of ours). We learned to treat you rather than treating ourselves.

We spend much of our time as physicians trying to heal; to tweak the leaky faucets, to quell the pulmonary seas, to dispel swelling when it accumulates where it should not. We forget that we must also “do no harm.” But you reminded us. You, with your heart and lungs and kidneys that grew weary after 90 years. You, with your nine children, nieces and nephews, younger siblings, grandchildren and great-grandchildren from every corner of the world. You, with your prowess in mental math. We came to know you, and in some way, we hope you came to know us, too. We wish we could tell you how much you taught us—to recognize our limits and embrace the realization that more is not always better. We wish we could tell you what a privilege it was to care for you. And we wish you could tell us whether we provided you with what we hoped in the end: a dignified and comfortable death.

The authors were granted permission by the family to tell this story.

Arnav Agarwal is an internal medicine resident at the University of Toronto. He is passionate about health advocacy, patient and resident narratives, medical education and clinical epidemiology research.

Calvin Santiago is a neurology resident at the University of Toronto. He is passionate about the intersection between art and medicine.

Sumedha Arya is an internal medicine resident at the University of Toronto. She is passionate about the medical humanities, as well as person-centered care.

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8 comments

RAMJanuary 16th, 2019 at 12:46 pm

I hope you, and others will in the health field will remember to be especially kind to single hospitalized people, with no family, who are dealing with chronic, incurable and painful illnesses. Visit us often. We have amazing stories to tell. Your company is curative.

This article feels incredibly contrived and cliche. Medical school and residency were never about trying to prolong life indefinitely to increase a number known as “age”. It was always about doing best for the patient regardless of what your person goal is (i.e. not solving the “puzzle” or “tweaking the leaky faucets”). To think that as a doctor was never correct. How many times do you need to write about these “experiences” before you realize that yourself? This same article has been written hundreds of time by medical students and residents alike.

Touching story, not only about this special patient, but also about the developing self awareness and personal growth of these resident physicians. As compassion for their patient evolved, they also began to recognize their own suffering in contributing to their patient’s suffering. Now then is an opportunity to not self-blame about how we as physicians could have done better, but to begin to practice non-judgmental self compassion, and learn humility as we listen to our patients’ messages about the importance of truly listening to our patients. When we do this, we will do better next time. As these resident physicians most certainly will.

It is good that you learned this lesson: it appears rather slowly. The fact that you had to learn it this way, and as pointed out by others, that you need to talk about this discovery, is a terrible condemnation of the medical schools that you came from: presumably Toronto, maybe others. Please go back to your alma mater and tell them that helping physicians to understand the balance of caring and palliative approaches is essential for all graduates. Insist that they develop a program, and perhaps change their examination system to ensure that this is learned by every graduate.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.